Intellectual leadership in medicine

This blog has been inactive for some time. The biggest reason is that I have been overwhelmed with medical school applications and interviews. I have added a new tab called “Hego’s Medicine.” This will reflect the fact that I am going to be a doctor and have a few things to say about that.

So, on with my first post in a while.

After 11 interviews for medical school, my experience is that bringing in theoretical issues to interview situations will virtually always prompt a negative response. I believe that I have probably lost acceptances because of this.

I think this situation is because physicians are generally not inclined to theoretical issues outside the sciences. The two pillars of medicine, as is often stated, are humanism and science. Humanism in medicine is defined in fairly emotional terms, whereas science, as we understand the term in the biomedical sciences, is a technical discipline. This leaves little room in the mainstream medical culture for theorizing in the sense that philosophers mean it. Therefore, you will generally be docked points in interviews, and even be suspected of being unfit for medicine, if you emphasize philosophical issues–that is, if you stray from this mainstream culture–and cannot directly relate this kind of thinking to concrete, hot topic-type issues in medicine.

I can understand this orientation on the part of interviewers. After all, interviewers want to admit those who will thrive in contemporary medical culture. And the culture itself reflects the conditions of practice that physicians currently must abide by. To draw and emphasize distinctions that are extraneous to the culture is, in a sense, to put one at odds with the ways that physicians are expected to practice. Can it then be expected that an individual inclined to such thinking will be the most suited among applicants to be a physician? I believe this is the implicit, not explicit, thinking on the part of interviewers. Interviewers usually just dislike hearing about things they do not know or care about, but I think this dislike unconsciously reflects the more general anti-theoretical orientation of contemporary medicine.

This way of thinking seems limiting to me in a few ways of significant practical importance. The biggest is that the healthcare system is currently in crisis. Adhering tightly to past standards re-entrenches current conditions; it does not encourage physicians that can think their way to the future. According to Paul Starr, physicians in the United States have a poor track record of leadership when it comes to reform. This should change, and I don’t think that the bias against more intellectually oriented people in medicine is compatible with this.

We know that there are health systems that reject both technological advance as a pillar for improving healthcare (and, according to any health economics textbook, rightly), as well as the emotionally humanistic orientation currently so prevalent in American healthcare culture–often outperform the United States in outcomes measures. I think the latest OECD report makes this clear (http://newsatjama.jama.com/2013/11/27/jama-forum-oecd-report-offers-a-contrast-in-perception-vs-reality-in-us-health-care/). To me, therefore, different ways of thinking about healthcare, within healthcare, are needed, if we want healthcare to change in the ways that it needs to change. With regard to compassion and altruism, specifically, it is obvious that there are many ways in which to be compassionate or altruistic. To me, the failure of physicians in leading healthcare to a better place is that they simply accept compassion (and good technology), narrowly and emotionally defined, as enough to provide good healthcare. As American health outcomes demonstrate, this clearly cannot be true. Therefore, this current emphasis in medical culture, if I am right in characterizing it, is wrong. As a result, I think the question with regard to our generation of physicians is not, “are you compassionate?” but rather, “in what way does, and should, your compassion affect your practice and your leadership within healthcare?” I believe the second question is exponentially better one for those who will provide for our future healthcare system.

I think that the question is also crucial at a personal, individual level–not just with respect to system-wide considerations. With physician burnout such a prominent phenomenon, potentially becoming worse in the coming years as physician expectations continue to diverge from the clinical reality (what with increased patient volume, decreased pay, etc.), to ask in what ways we are “altruistic” is essential: how, after all, should we reconcile our personal needs with that of the patient’s? To say that we want to put the needs of the patient over the needs of ourselves, and to leave it at that, would be irresponsible from this point of view; it could lead, and probably does, to physician burnout among those who have not been challenged (or challenged themselves) to think about and come to healthy conclusions about how to be altruistic. Again, the question is not, “are you altruistic?” but rather, “in what way?” This is essential requires conceptual, and not emotional thinking. To the degree that this kind of thinking is not an emphasis in medical admissions and training, I think physicians and healthcare as a whole suffer.

I say therefore that not only do many physicians not care about such distinctions, but that they are wrong not to care. What, therefore, do we do? How do we reconcile what is right, with the current limitations of the profession? How do we reconcile the needs of our training with own personal and professional needs — even the needs of society? The answer comes from Kant. Kant distinguished between the private and public use of reason. The private use of reason is when conducting one’s function: one uses reason solely for the purpose of fulfilling one’s occupational and social obligations. The public use of reason, on the other hand, occurs when one is not doing one’s job: when he is writing, when he is talking with friends or the public. In the case of medical school interviews, and medical school training, and I think even as our lives as physicians, I think that, when we must, we simply do and say what we are supposed to. This is different from “playing the game”. The idea of “playing the game” is too cynical. It suggests that we don’t believe in the values of the profession. But I for one do. It’s just that the values of the profession are too simple-minded to be realistic or even morally sound. So, we do what we need to do in the short run, in order to make a positive impact in the longer run. This division in oneself requires discipline, fortitude, and practice, but I think it is necessary if we are going to lead authentic lives and leave something positive for the next generation after us.

Cultural change is a process that must take decades, and bureaucratic life can be soul crushing. Much less can I deny the juggernaut inertia of our healthcare system and its culture. I just think that this distancing of ourselves from ridiculous aspects of our institutions is not a cause for bitterness, but rather an obvious call and opportunity to make a difference. It is possible, and these days, absolutely necessary. This much is not even a choice.

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